Provider Demographics
NPI:1790235315
Name:BROADWAY FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:BROADWAY FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUGGAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-955-2022
Mailing Address - Street 1:15 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5007
Mailing Address - Country:US
Mailing Address - Phone:973-955-2002
Mailing Address - Fax:
Practice Address - Street 1:15 BROADWAY
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5007
Practice Address - Country:US
Practice Address - Phone:973-955-2002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223E0200X, 1223P0300X, 1223S0112X, 124Q00000X
NJ22DI0206891223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty